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| Sexual dysfunction in women suffering from major depressive disorder: A cross-sectional study |
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Ranjit Kumar Pindikura1, K Uday Kumar2, Javangula Swetha Krishna3
1 Associate Professor, Department of Psychiatry, Narayana Medical College & Hospital, Nellore, Andhra Pradesh, India
2 Professor, Department of Psychiatry, Narayana Medical College & Hospital, Nellore, Andhra Pradesh, India
3 Post graduate, Department of Psychiatry, Narayana Medical College & Hospital, Nellore, Andhra Pradesh, India
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| Date of Submission | 09-Jun-2022 |
| Date of Acceptance | 06-Jul-2022 |
| Date of Web Publication | 04-Aug-2022 |
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Background: Compared to a healthy population, sexual dysfunction is higher in major depressive disorder (MDD). Identification and management of sexual dysfunction profoundly impact marital satisfaction, quality of life, and compliance with treatment in patients with depression.
Aims and Objectives: The primary objective was to determine the proportion of sexual dysfunction among women suffering from MDD attending the psychiatry department of a tertiary care center. The secondary objectives were (1) to study the correlation between the severity of depression and sexual dysfunction in women with MDD and (2) to study the relationship between sociodemographic and clinical variables with sexual dysfunction.
Settings and Design: This was a cross-sectional study carried out among 40 women diagnosed with MDD attending the psychiatry department of our tertiary care institute.
Materials and Methods: After taking informed consent, relevant sociodemographic details and clinical variables were recorded using a semi-structured questionnaire. MDD was diagnosed according to the Diagnostic Statistical Manual of Mental Disorders-Fifth Edition, and its severity was assessed using Hamilton rating scale for depression. Sexual dysfunction was measured using the Arizona sexual experience scale.
Statistical Analysis: Spearman's correlation coefficient was used to assess the correlation between the severity of depression and sexual dysfunction. The Chi-square test was used to test the relationship between categorical variables. Analysis of data was done using appropriate statistical software.
Results: The proportion of sexual dysfunction among women with MDD was 65%. The most common sexual dysfunction was low sexual desire (57.5%). There was a positive correlation between the severity of depression and the presence of sexual dysfunction, with Spearman's correlation coefficient (rho = 0.765, P = 0.000). Age, attainment of menopause, history of alcohol and tobacco use in the spouse, and severity of depression were significant with sexual dysfunction using the Chi-square test.
Conclusions: The proportion of sexual dysfunction was high among women suffering from MDD. The severity of depression and the presence of sexual dysfunction are positively correlated.
Keywords: Cross-sectional study, depression, quality of life, sexual dysfunction
How to cite this URL:
Pindikura RK, Kumar K U, Krishna JS. Sexual dysfunction in women suffering from major depressive disorder: A cross-sectional study. Arch Ment Health [Epub ahead of print] [cited 2023 Mar 26]. Available from: https://www.amhonline.org/preprintarticle.asp?id=353460 |
| Introduction | |  |
Depression is the most common psychiatric disorder. Globally, more than 300 million people of all ages suffer from depression. In 2008, major depression was ranked as the third leading cause of burden of disease by the World Health Organization.[1]
Depression is more common among females (5.1%) than males (3.6%).[2] The lifetime prevalence of major depressive disorder (MDD) is 10%–25% for women and 5%–12% for men.[3] Women are more prone to suffer from depression, and depression is the leading cause of disability.[4]
Sexuality is a core dimension and an integral part of being human. Sexual intimacy contributes to a healthy relationship and individual well-being. Human sexuality involves the integration of biological, psychological, and sociocultural dimensions that interact with each other. Sexual dysfunction is very high in females with MDD,[5] and a widely accepted model is the disruption of the human sexual response cycle due to the underlying depression.[6],[7]
Female sexual dysfunction (FSD) can occur in different forms such as hypoactive sexual desire disorder, female sexual arousal disorder, dyspareunia, and female orgasmic disorder. Depression itself causes loss of libido, negatively affects arousal and orgasm, and causes emotional withdrawal from the partner and subsequent performance anxiety regarding sex. A recent meta-analysis showed a bidirectional association between MDD and sexual dysfunction.[8] Sexual dysfunction could also be due to the adverse effects of some antidepressants though they are the most important and effective strategies for the management of depression.[9]
Reddy et al. did a hospital-based, cross-sectional, comparative study over 1 year with 270 participants. They reported that the prevalence of FSD was about 40% in cases and 11.1% in the controls in their study.[10] Sreelakshmy et al. did a similar study in Tamil Nadu; it was a hospital-based, cross-sectional study done for 6 months including 142 women suffering from MDD. They reported that 90% of them suffered from FSD, the most common being hypoactive sexual desire disorder followed by female sexual arousal disorder.[11]
Patients suffering from MDD report higher rates of sexual dysfunction than do members of a healthy population.[12],[13] FSD in India is often underreported and an underestimated health condition linked to social and cultural taboos. It is discussed in hushed voices and discovered behind closed doors. Only a few studies in our country have addressed these serious health issues despite their profound impact in terms of marital relationships, compliance with medications for depression, and overall quality of life. Hence, this study has been done to cover these lacunae to gain a more comprehensive understanding of FSD in women suffering from depression.
| Materials and Methods | | |
Design
This is a descriptive, cross-sectional design. It was done in the psychiatry department of our tertiary care institute, and all the assessments were done once. The patients were recruited between January 2022 and April 2022.
Sampling technique
All the consecutive cases meeting the eligibility criteria were selected.
Sample size
The sample size was collected using the formula n = 4pq/d2, where P is the prevalence of sexual dysfunction among women with MDD. We took P as 0.75 based on a previous study done by Thakurta et al.[14] q = 100 − p, d (relative precision) =20% of p. We got n = 33 rounded to 40.
Inclusion and exclusion criteria
Married women in the age group 18–50 years of age, diagnosed with MDD according to the Diagnostic Statistical Manual of Mental Disorders-Fifth Edition, and willing to give consent were included in the study. Patients with psychotic symptoms and unwilling to participate in the study were excluded.
Materials
Sociodemographic profile sheet
It was developed for the study. It is a semi-structured pro forma with variables such as age, education, occupation, and socioeconomic status.
Clinical profile sheet
This was used to collect data regarding clinical variables such as medications, menopause, comorbid systemic illness, history of gynecological surgeries, and substance use.
Hamilton depression rating scale
This is one of the most widely used instruments for the assessment of depression. It is used to quantify the severity of depressive symptoms and is a clinician-administered scale. It contains 17 items pertaining to the symptoms of depression experienced by the patient over the last 7 days. Cronbach's α is 0.74 demonstrating adequate internal consistency.[15] A score of 0–7 is accepted to be within the normal range or in clinical remission. A limitation of this scale is that atypical symptoms of depression are not assessed.
Arizona sexual experiences scale
Arizona sexual experiences scale (ASEX) is a five-item validated patient-rated rating scale. It quantifies sex drive, arousal, vaginal lubrication or penile erection, ability to reach orgasm, and satisfaction from orgasm. The scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. Sexual dysfunction is defined as a total ASEX score of ≥19 or any item with an individual score of ≥5 or 4 or more on any three items. Cronbach's alpha analysis demonstrated excellent internal consistency and scale reliability (α =0.9055). It also demonstrated strong test–retest reliability (r = 0.801, P < 0.01 for patients and r = 0.892, P < 0.01 for controls).[16]
Methodology
The study was commenced after obtaining ethical clearance from the institutional review board. Patients seen in the outpatient department of psychiatry and fulfilling the inclusion and exclusion criteria were recruited into the study. Written informed consent was taken from the participants after explaining the design and nature of the study in their native language.
Data were obtained on the sociodemographic and clinical variables using the investigators' specially designed semi-structured pro forma. Each participant was administered the Hamilton rating scale for depression (HAM-D) to assess the severity of depression in each case. The ASEX was used to analyze the subjective sexual experience.
Statistical analysis
Categorical variables were expressed as proportions, and quantitative data were expressed as mean and standard deviation. The Chi-square test was used as a statistical test of significance for categorical variables. Correlation analysis was done using the Spearman's coefficient. Analysis was done using appropriate software. For all test parameters, P < 0.05 was considered statistically significant, and confidence interval is set at 95%.
| Results | | |
The mean age of the study subjects was 39.4 ± 8.22 years. The majority of the patients belonged to an age group of 34–47 years. Only women were taken in the study. Most of the participants were from below the poverty line, received up to secondary education, and were unemployed [Table 1]. | Table 1: Distribution of sociodemographic variables in the study population
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10 (25%) of them had comorbid systemic illnesses, with hypothyroidism the most common. A few of them, i.e. 2 (5%), had gynecological surgeries in the past. 9 (22.5%) of the patient's spouses consumed alcohol, and 6 (15%) of them used tobacco [Table 2].
The majority of the patients (40%) had mild depression [Table 3]. Sexual dysfunction was seen in 26 (65%) patients [Table 4]. The most common complaint (57.5%) was having a low desire [Table 5]. The mean HAM-D score was 14.9 ± 4.39 standard deviation. The mean ASEX score was 20.4 ± 4.99 standard deviations [Table 6]. | Table 3: Distribution of severity of major depressive disorder based on Hamilton rating scale for depression scores
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 | Table 4: Distribution of presence of sexual dysfunction among study subjects
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 | Table 5: Distribution of nature of sexual dysfunction based on Arizona sexual experience scale items
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 | Table 6: Mean and standard deviation of Hamilton rating scale for depression scores and Arizona sexual experience scale scores
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There was a positive correlation between the severity of depression and the presence of sexual dysfunction on correlation analysis. Spearman's rho was found to be 0.765 and had a significant (P = 0.000).
We studied the characteristics of patients in relation to the presence of sexual dysfunction by Chi-square test. There was a statistically significant association between age and sexual dysfunction (χ2 = 10.144, P = 0.038). Attainment of menopause showed a significant association with depression (χ2 = 4.79, P = 0.029). Alcohol use in the spouse showed a significant association with sexual dysfunction (χ2 = 1.604, P = 0.021) along with tobacco use in the spouse (χ2 = 4.79, P = 0.029). Sexual dysfunction in depressed women did not show any statistically significant association with socioeconomic status, education, occupation, medications, and comorbid systemic illnesses [Table 7]. | Table 7: Characteristics of patients according to the presence of sexual dysfunction (Chi-square analysis)
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Our study was done to assess the proportion of sexual dysfunction in women suffering from MDD and also to correlate the severity of depression with sexual dysfunction in them. We also intended to study the relationship between sociodemographic and clinical variables in these women with sexual dysfunction.
In our study, the proportion of overall sexual dysfunction in women with MDD was 65% (n = 26) of the patients. The findings in our study were comparable to the study done by Roy et al.,[17] who showed a prevalence of 70%. Another study done by Abhivant and Sawant on 49 study subjects showed a prevalence of 67.34% similar to our study.[18] Maru et al. showed a prevalence of 74.55% using ASEX which was slightly higher than ours, perhaps due to the sensitivity of the instrument in a different setting.[19]
Low desire or decreased libido was the most common sexual dysfunction in our study, followed by difficulty with arousal. The findings were comparable to a study done by Thakurta et al., who reported that 42% of depressed women reported decreased sexual interest and 8%–22% of them decreased sexual arousal.[14] Mathew and Weinman in a comparative study reported that alterations in libido were more common in depressed patients, but the prevalence of orgasmic dysfunctions did not differ significantly from the control population.[20] We found a positive correlation between the severity of depression and the presence of sexual dysfunction in our study by doing a correlation analysis. Similar findings were reported in studies done by Thakurta et al.,[14] Mohammadi et al.,[21] and Zivadinov et al.[22]
Our study found that sexual dysfunction worsened with aging, in women suffering from depression. Camacho et al. reported similar findings that FSD increased with age.[23] Attainment of menopause was also found to be a significant factor for sexual dysfunction in our patients. The study by Castelo-Branco et al. also found menopause as one of the risk factors for sexual dysfunction with an odds ratio of 3.3 (1.6–6.9) with P < 0.001.[24]
In our study, the spouses of men who used either alcohol or tobacco showed statistically significant sexual dysfunction compared to the remaining women suffering from depression. These findings were similar to those in the other studies, e.g. O'Farrell et al. who reported that spouses of alcoholics showed less frequent intercourse, an increased desire for change in its frequency, and also more disagreements about sex with their partners.[25] Peugh and Belenko in their review on alcohol, drugs, and sexual function concluded that a history of tobacco use in the spouse increased the odds of having sexual dysfunction, and it could be due to male sexual dysfunction.[26]
An increase in the severity of depression showed a significant worsening in sexual functioning in our study. Fabre and Smith also reported comparable findings. They reported that with an increase in HAMD scores, sexual dysfunction scores got worsened (Lower Derogatis Inventory of Sexual Function scores).[27]
There were some limitations in our study. It was a cross-sectional study, and hence, causal relationship could not be established. Factors such as marital disharmony, domestic violence, and sexual dysfunction in the spouse were not considered, contributing to the FSD. Details of the duration of treatment or the class of medications were not taken into consideration, and some antidepressants are known to contribute to sexual dysfunction.
Depression and sexual dysfunction are very commonly associated with comorbid conditions. Sexual functioning determines one's quality of life. A therapist who identifies and treats the sexual dysfunctions would aid in enhancing the quality of life in these patients. We recommend researchers use a longitudinal study design, include clinical variables contributing to sexual dysfunction in the spouse, and also consider the details of treatment used for further study.
| Conclusions | | |
The proportion of sexual dysfunction in women with MDD is 65%. There is a positive correlation between the severity of depression and the presence of sexual dysfunction with a Spearman's correlation coefficient (Spearman's rho = 0.765, P = 0.000). Low desire or decreased libido was the most common sexual dysfunction. Attainment of menopause, history of alcohol or tobacco use in the spouse, and the severity of depression were significantly associated with sexual dysfunction.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Correspondence Address:
Ranjit Kumar Pindikura,
Department of Psychiatry, Narayana Medical College and Hospital, Nellore - 524 002, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_92_22
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7] |
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